Request Form - The College of Opticians of Ontario

Provider Information

Name of Organization:*

First Name:*

Last Name:*

Position:

Address:*

Suite:

P.O Box:

City:*

Province:*

Postal Code:*

Phone:*

Fax:

Email:*

Materials Submission

You will be required to upload the following Materials:

Short biography or CV specifying the professional designation and or title, education, and affiliation of each speaker.
Up to three supporting material documents
A Powerpoint Presentation

Once you have submitted your request, you will be redirected to a new form/page where you will upload the materials. Please upload materials in PDF format. You will also receive an email message containing a link to this form/page.

CE Activity Submission Information – Supporting Documentation Required

Exact title of CE activity submitted:*

Type of CE activity (please check all that apply):*

Contact Lens (CL)
Eyeglass (EG)
Refracting (RF)
Professional Growth
Live Presentation
Distance Learning/Online

Date(s) of CE activity:*

Length of CE activity:*

Is this a previously accredited CE activity?:*

Yes

No

Speakers(s)*

1. Full Name:*

Title/position:*

2. Full Name:

Title/position:

Location of CE Activity – if applicable

Name of Venue:

Address:

Suite:

P.O Box:

City:

Province:

Postal Code:

Phone:

Fax:

Email:

Learning Outcomes of Activity

Please describe, in detail, the specific learning outcomes of the submitted activity (skills, activities or items of information) which attendees will be expected to incorporate into their professional duties:*

National Competencies

Please list the National Competencies covered within this activity:*

Data Sources

Please provide a list of all reference materials relied on in developing this activity:*

NOTE: It is expected that all presentations will cite at least one reference source (e.g. journal articles, textbooks, websites, etc.). Citations should be provided for all ideas, statistics, and other data, including formulas and diagrams, that were not created by the presenter. Presenters should also indicate if any of the material is based on their own professional experience.

Review Fee and Timeline

Please indicate the requested review fee and timeline:*

Standard Accreditation Review - $84.75

(Submitted more than 45 days prior to the scheduled event)

Fast Track Accreditation Review - $226.00

(Submitted between 45 to 10 days prior to the scheduled event)

Rush Accreditation Review - $565.00

(Submitted less than 10 days prior to the scheduled event)

By checking this box, I am authorizing the College to charge the selected review fee to the credit card on file with the College.

Protecting the Public

Continuing Education Activity Accreditation Request